11/10/2016 4:26 PM |
Anonymous

The intent of this space is to highlight research and its implications for clinical practice. When we envisioned this space, I, at least, thought that we would be looking at the current research literature – and I expect that much of what we review will be from the current literature (indeed, other entries – see here and here- are). But Sydney Blatt’s work, work that I was not exposed to during my training, is so compelling that I do think it deserves mention. Since I was not exposed to it, I’m not sure that this paper is the best representation of it, but I do think it articulates some basic ideas that may have been fleshed out later in slightly different ways. I also think there may have been more compelling data that he later produced that supported the importance of long term depth therapy, but I (admittedly an easy mark) am quite convinced by what he references in this paper.

Blatt’s central premise in much of his work is that there are two kinds of depression – a dependent style, which Blatt calls the anaclitic, and a self-critical style, which he calls the introjective. Blatt articulates in this paper – and doubtless elsewhere – that these styles are empirically supported and that they grow out of a theoretical assumption about a continuity between normal reactions to inevitable life events and reactions to severe disruptions. These events cluster around two developmental poles – building interpersonal connections (or failing to do so) and creating individual and autonomous competencies that the person has confidence in (or failing to do so). In this developmental model, when things go well, a positive, self-reinforcing spiral takes place in which increased interpersonal competence and confidence leads to increased abilities to take on and succeed at tasks independently. When things go poorly, a similar, but much more destructive spiral ensues, where interpersonal failure undermines the capacity function independently and vice versa.

Despite the interrelationships between the two tasks, Blatt observed that there are distinct clinical presentations depending on how the trauma has been experienced. Anaclitic depression, the dependent style, is characterized by a profound sense of loneliness, and a consequent sense of need for connection. The person feels, especially when unsupported, helpless and weak. They seek others out in order that they can get their needs for support, succorance, and love met by them.

Introjective depression – the autonomous kind, on the other hand, is characterized by intense self-criticism and there is frequently, then, an intense drive for achievement to offset the internalized sense of inferiority and self-scrutiny. These individuals can be extremely critical of others as well as themselves and can be intensely competitive, often achieving a great deal, but with little sense of satisfaction – no amount of external validation seems to satisfy the harsh and demanding person that they can be in relationship to themselves.

One reason that I like this paper in particular is that Blatt is taking what he knows and applying it more broadly. He starts by referring to three publicly described cases of perfectionism that resulted in suicide, including Clinton’s deputy counsel, Vincent Foster, someone whom many had considered a potential future Supreme Court Justice. Blatt makes the case, based on evidence he provides, that these individuals would likely have benefited from long term intensive treatment – and, interestingly, were not likely to have received similar benefit from either short term care or from psychopharmacological treatment. He nicely describes these individuals, their strengths, and what they had to offer society, and then deftly weaves their perfectionism into his system of organizing pathology.

He then goes beyond this to use this system to organize a variety of pathological styles, making a case for using this dichotomy to organize our system of pathology. The nice thing about this is that it is not an empty exercise in putting things into boxes, but it has clear clinical and treatment implications – what kind of treatment are patients in the two groups likely to best respond to? This kind of hypothesis is then testable – and we are off to the races – including being able to justify the expense of psychoanalytic treatment in certain cases. If we are ever to move away from people getting the treatment they need through paying for it themselves (and, fortunately, those introjectives who are reasonably successful are those who are most likely to be able to afford longer term treatments) – but his point is that this is a societal value. We should also question whether a more supportive and action oriented treatment like DBT or more supportive psychodynamic treatments might be more successful for some of our patients – particularly, as I read it, for the more Anaclitic/Dependent patients.

While I have not yet given this paper to a client (though I may at some point), I have integrated it into my psychopathology syllabus for the current candidate class at our institute. I hope that they profit from it. I think that being able to use a diagnostic understanding to help us think about how best to meet the needs of a particular patient so that we can help get them back onto a developmental track makes this research clinically useful.

If you are interested in responding to this post, please do so below. If you have read a research article recently that you think would be of interest to an audience of clinicians and would like to write a summary of that, please send it as an email link to Karl Stukenberg at stukenb@xavier.edu. Include the words “Clinicians Reading Research” in the subject line.